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Telemedicine: Its Effects on Health CommunicationJonathan Matusitz a & Gerald-Mark Breen ba University of Central Florida ,b University of Texas–Pan American ,Published online: 05 Dec 2007.

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HEALTH COMMUNICATION, 21(1), 73–83Copyright © 2007, Lawrence Erlbaum Associates, Inc.

Telemedicine: Its Effects on Health Communication

Jonathan MatusitzUniversity of Central Florida

Gerald-Mark BreenUniversity of Texas–Pan American

This article analyzes telemedicine, the use of distant communication technologies within thecontext of clinical health care, and the effects it has on health communication. The maineffect is that telemedicine has the capacity to substantially transform health care in bothpositive and negative ways and to radically modify personal face-to-face communication(Turner, 2003). This has tremendous implications for health communication scholars in thatthey can extend the telemedicine debate by integrating fresh insights into more acceptableapproaches that will refine and humanize mediated channels of health communication. Thereare several key areas of telemedicine that need to be discussed (i.e., e-health services, clinicalencounters, etc.), all of which are identified in this article. In addition to describing thepast and current applications of telemedicine, this article provides a better understanding ofunique needs, resources, problems, and opportunities germane to telemedicine services.

This article analyzes telemedicine, the use of distant commu-nication technologies within the context of clinical healthcare, and the effects it has on health communication. Themain effect is that telemedicine has the capacity to substan-tially transform health care in both positive and negative waysand to radically modify personal face-to-face communica-tion (Turner, 2003). This has tremendous implications forhealth communication scholars in that they can extend thetelemedicine debate by integrating fresh insights into moreacceptable approaches that will refine and humanize medi-ated channels of health communication. There are severalkey areas of telemedicine that need to be discussed (i.e., e-health services, clinical encounters, etc.), all of which areidentified in this article. In addition to describing the pastand current applications of telemedicine, this article providesa better understanding of unique needs, resources, prob-lems, and opportunities germane to telemedicine services.Specifically, what distinguishes this analysis from otherliterature reviews on telemedicine is a more refined set ofinsights that contrast the benefits of telemedicine to the chal-lenges that it poses. Although telemedicine has the abilityto transcend geographical boundaries; transcend temporalboundaries; reduce costs; increase patient comfort, security,and satisfaction, and to digitize health communication via

Correspondence should be addressed to Jonathan Matusitz, AssistantProfessor, Nicholson School of Communication, University of CentralFlorida, Orland, FL 32816. E-mail: matusitz@hotmail.com

Web-based services, telemedicine creates serious questionsthat obstruct or threaten its growth and implementation invarious ways. Whereas Turner (2003) identified a varietyof challenges that endanger the advancement and successof telemedicine, we consider four that dominate the rest,and we clarify these in more detail than have been providedin earlier research: (a) licensing and legal issues, (b) chal-lenges to patient privacy, (c) resistance from health insur-ance companies, and (d) limited knowledge and expertisein telemedicine. Finally, this article examines one partic-ular negative aspect of the use of telemedicine that has oftenbeen overlooked: the subtractive communicative effects thatit has on both health care practitioners and patients. Ourgoal here is to extend and solidify previous studies (Roback& Herzog, 2003; Short & Saindon, 1998) that have indi-cated that the use of telemedicine can make communica-tion and social interaction reduced to such a point that thispractice is arguably deemed as dissocializing and dehu-manizing. This article ends with a section that includes adiscussion and suggestions for future directions for healthcommunication scholars.

WHAT IS TELEMEDICINE?

Telemedicine is the use of advanced communication tech-nologies, within the context of clinical health, that deliver

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care across distance (Turner, 2003; Turner, Thomas, &Reinsch, 2004). As such, it facilitates the delivery of tele-health care for the direct benefit of patients (Perednia &Allen, 1995; Wootton, 2001). Those distant communicationtechnologies range from the telephone to state-of-the-artequipment that allows physicians, nurses, and other alliedhealth professionals to provide health care hundreds oreven thousands of miles away from the point of service(Conrad, 1998). Besides, not only is telemedicine a prac-tice that can be applied in multiple medical settings, but italso facilitates and accelerates communication (viz., inter-change, correspondence, and dialogue) between medicalpractitioners and their patients. It does so between loca-tions of clinical practice for the purposes of relief and/oreducation (Ausseresses, 1995). The broad range of appli-cations for telemedicine consists of patient care (Street,Wheeler, & McCaughan, 2000), training, research, adminis-tration, and public health to diagnose, provide care, transmithealth information, examine X-rays, provide services, andtrain health professionals (Conrad, 1998). Telemedicinenowadays even includes Internet-based services such asWebMD.com, an on-line service that provides rich andreadily accessible medical and pharmaceutical informationthat may significantly reduce the need for actual consulta-tion with medical practitioners and pharmacists.

PAST APPLICATIONS OF TELEMEDICINE

The history of distant medical assistance through communi-cation and technology stretches back as far as to the timeswhen electronic devices were first introduced to society. In thepast century, the use of telegraphy, telephony, radio, televi-sion, and wireless communication have assisted in physician–patient communication (Wootton, 1998). Although therehas been much debate regarding the first official usage oftelemedicine services, the first cited telemedicine application,according to Perednia and Allen (1995), took place in 1959.A study was conducted to show the benefits of a unique formof telemedicine in the telepsychiatry setting. As such, theuse of a two-way closed-circuit microwave television systemprovided successful telemedicine communication, training,and research between the Nebraska Psychiatric Institute andNorfolk State Hospital in Nebraska (Turner, 2003; Wittson &Benschoter, 1972).

Later, the National Aeronautics and Space Administra-tion (NASA) played an important role in further developingtelemedicine when astronauts first began flying in space.The physiological conditions of the crew were reportedvia communication satellites from both the spacecraft andthe suits that the astronauts wore during missions. Theseimprovements in space were applied to rural medicine inthe early 1970s through the Space Technology Applied toRural Papago Advanced Health Care program (Ausseresses,1995), as well as distant areas, isolated communities lacking

medical care (i.e., in mountainous areas, islands, openplains, and arctic regions), and developing and Third Worldcountries (Wright, 1998). Telemedicine became signifi-cantly more important in the 1980s, when costs decreasedfor many of the information and communication technolo-gies on which the efforts depended.

TELEMEDICINE TODAY: FOUR TYPES OFAPPLICATIONS

Today, numerous research studies have shown thattelemedicine, in its various forms and applications, is amedical practice that is increasingly used for medical treat-ment and services (Mair & Whitten, 2000). Accordingto Balas et al. (1997), studies focusing on telemedicinein clinical settings demonstrate that this communicativemodality offers enhanced performance, propitious results,and meaningful advantages. Telemedicine can be classi-fied into various approaches or applications based on theparticular niche of healthcare. According to Grigsby (1997),there are four suggested types of telemedicine applications:(a) management of specific diseases, (b) use within specificspecialties, (c) classification according to technology, and(d) types of clinical problems.

Management of Specific Diseases

Within the context and scope of specific diseases,telemedicine can be defined with regard to its applica-tion in the management of various diseases, conditions,or pathologies (Turner, 2003), such as those related todermatological (Lesher et al., 1998), cardiological (Wirthlinet al., 1998), and respiratory (Nuccio, 2004) diseases. Inthese situations, a specific diagnosis is made, and thenthe disease is treated using the most appropriate form oftelemedicine services available. Past studies have demon-strated that increased access to telemedical devices has beenapproved and embraced among individuals with chronic anddebilitating diseases (Tetzlaff, 1997).

Use Within Specific Medical Problems

Within the realm of specific medical problems and specialistprimary-care consultations (Street et al., 2000), terms andpractices such as teleophthalmology, telepsychiatry (Baeret al., 1995), telepathology, and teledermatology apply(Turner, 2003). Other special sectors where teleconsulta-tions are conducted include the divisions of mental health,intensive care units, rehabilitation (Field, 2002), cardiology,surgery, and dermatology (Grigsby & Allen, 1997). In otherwords, the basis of specific medical problems with respectto telemedicine simply involves the integration and imple-mentation of telecommunications devices in the context ofeach of the aforesaid medical areas.

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Classification According to Technology

Within the frame of communication and technology, thisarea identifies the various forms that telemedicine cantake, such as everyday electronic devices, including tele-phones, fax machines, video transmission (Squibb, 1999),camera light boxes, videoconferencing (Capner, 2000),multimedia, electronic mail (e-mail) services, remote moni-toring systems, and interactive television units (Turner,2003). More recently, Nuccio (2004) identified a series ofnewly patented telemedicine devices; these include, amongothers, order entry systems and smart alarms. These devicesare designed to deliver medical care as an attempt to mini-mize the gap between the availability of expertise andservices in unequipped locations. In particular, smart alarmsare telemedicine systems because they are technologicalapparatuses that transmit vital information about a patientto medical personnel when a clinical emergency is takingplace. Order entry systems are inventory control systemsthat communicate health-related needs between the providerand the patient (i.e., medication refills, etc.; Thames, 2003).

Types of Clinical Problems

According to Grigsby (1997), categorizing telemedicine onthe basis of the specific clinical problem refers to the proce-dures that are used in any particular telemedicine commu-nication. As such, in considering the forms of telemedicinesuch as teleradiology and telepathology, what is generallyinvolved in these cases is the electronic transmission ofdiagnostic medical pictures and clinical data originatingfrom a location of unspecialized medical service to one ofhighly specialized clinicians (Turner, 2003). In this type ofscenario, the data, once received by the specialized clinician,can be analyzed to determine the correct medical approachto take. Once the specialist has reached a determination,an answer can be subsequently communicated back to theinexperienced practitioner seeking guidance and directionon how to handle the patient under his or her direct super-vision. With this type of interfacing, it may be possible forhealth care facilities in small, isolated regions and, by thesame token, lacking expert practitioners, to obtain guidancefrom specialists located just about anywhere in the world.

TELEMEDICINE APPLIED ON MILITARYGROUNDS AND IN PRISONS

Aside from the standard hospital or medical settings wheretelemedicine practices are applied, telemedicine has beenwidely used in military settings and prisons (Turner, 1999,2003). These locations, as well as private health care orga-nizations such as health maintenance organizations and theVeterans Administration, provide a valuable prospect forefficient and cost-effective telemedicine use (Grigsby &Allen, 1997). Especially in the military arena, telemedicine

can provide immediate communicative services to indi-viduals treating combat casualties in battlefields. Indeed,telemedicine services can circumvent the need for a physi-cally present physician, a normal requirement for managingand caring for serious injuries (Edwards & Motta, 1997),while still treating the patient with some hope at recovery.

Similarly, patients are sometimes treated withtelemedicine procedures on a prison ground. Accordingto a research study conducted by Mekhijan et al. (1999),patient satisfaction, among the subjects, was identified withregard to the informational and relational dimensions of thetelemedicine treatment. An earlier study by Allen and Hayes(1994) produced similar findings in that patient satisfactionwas high as a result of the ease of access and the physi-cian’s methods of communication within the telemedicineapplication.

TELEMEDICINE APPLIED IN NURSING

Besides the medical doctors who oftentimes dominate inthe telemedicine realm, the role of nurses has widened andhas slightly pervaded into telemedicine practices as well,particularly in dialysis units. According to Turner (2003),nurses who were involved in this particular setting (dial-ysis units) expressed that they appreciated telemedicineapplications in that department. They felt that increasedcontrol was granted to them in treating and communi-cating with their patients while the supervisory doctorswere absent. Especially in cases of managing chronicallyill patients in their homes, telemedicine can allow nursesto visit the home (Allen et al., 1996), conduct relevantexaminations, and communicate whatever information isneeded to the off-site physician. More important, even ifa home patient suffering from a disease such as diabetesrefuses or cannot access the assistance of a nurse at acertain time, that patient can directly communicate hisor her diabetes-related information to the doctor throughtelemedicine devices and can expect an immediate responsefrom that doctor on what to do next. In a similar vein,patients who do receive a home nurse can rely on them toconvey the information to the doctor located at the clinicor hospital (Mun & Turner, 1999), and the nurses canreceive feedback from the doctors and know how to proceedaccordingly.

WebMD.com AS A LEADER FOR ON-LINETELEMEDICINE SERVICES

In light of the recent increases of cyberization of health(Rusovick & Warner, 1998) and convergence to on-linehealth care information, WebMD.com (2005) outrightdeclares that it ranks first in providing services that helpmedical practitioners, consumers, and providers navigate

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the complex medical care system. More specifically, it helpsthese individuals interact with each other through e-mailservices and supplies an abundance of health care infor-mation with respect to symptoms, assisting in the diag-nostic process (although online clinical diagnostic poweris contingent on state law in most cases; Stanberry, 2001),treatments, and general medical recommendations. Fromthese provisions, it follows that WebMD.com is clearly atelemedicine service, emphasizing that “its products andservices streamline administrative and clinical processes,promote efficiency and reduce costs by facilitating informa-tion exchange, communication and electronic transactionsbetween healthcare participants” (WebMD.com, 2005). It isinteresting that WebMD.com categorizes and separates itsassistance into several subdomains that conveniently allowhealth care providers and consumers to seek informationand programs relevant to their particular needs or interests atthe time. Specifically, the WebMD.com site offers distinctservices, such as WebMD Health (WebMD.com, 2005).Although other diverse and prominent services besidesWebMD Health are available, this service is paramount andrequires discussion.

WebMD Health is the foremost supplier of online infor-mation, instructional services, and communicative outletsfor physicians and consumers (WebMD.com, 2005). Assuch, these forms of aid include disease and treatmentinformation (i.e., diagnoses, symptoms, common treat-ment protocols, etc.), pharmaceutical information (i.e.,side effects, prices, contraindications, warnings, etc.), andforum/interactive communities (or interface) for medicalpractitioners and consumers to communicate informationto one another. With this particular service, more than 20million people visit the site every month (WebMD.com,2005). This huge number of consumers represents aclear sign that on-line communication between healthcareproviders and consumers is substantially on the rise and isbecoming a primary communication channel through whichthese individuals seek and supply health-related information(aside from visiting doctors and other medical practitioners).

HEALTH COMMUNICATION BENEFITS OFTELEMEDICINE

The previous section demonstrated that telemedicine,whether through medical practitioners or direct online chan-nels, has been widely used and accepted as a viable optionin a diversity of areas, specialties, diagnostic conditions,and applications (Hailey, Ohinmaa, & Roine, 2004; Turneret al., 2004). More important, the use of telemedicinedemonstrates that health communication between the patientand the health care provider has been made more rapidand efficient. Nevertheless, we would hope and expect thattelemedicine be more readily embraced as a tool by allmedical specialists who desire to discover and ascertain its

maximum potential and utility. In fact, telemedicine offersa manifold of health communication benefits to both prac-titioners who engage its services and the health care systemin general. Every individual can benefit from telemedicine,from the patient, to the community, to physicians and otherpractitioners. With this prospect in mind, let us now proceedto the following section, where key benefits of telemedicineapplications and features are addressed and examined. Thesebenefits of telemedicine can be classified according to fivemain abilities: the ability of telemedicine to (a) transcendgeographical boundaries; (b) transcend temporal bound-aries; (c) reduce costs; (d) increase patient comfort, security,and satisfaction; and (e) digitize health communication viaWeb-based services.

Ability to Transcend Geographical Boundaries

Telemedicine can alleviate the issue of imbalances ingeographic allocation of resources, facilities, and personnelin the realm of health care. As such, it increases andstrengthens access to health communication and servicesamong disadvantaged, disserved, secluded, and restrictedcommunities and citizens (Crowe, 1998). For instance,surgeons located in “remote areas” (Perednia & Allen,1995) and who do not have the skills or experienceto handle a particular surgical procedure can call on,through telemedicine technologies, the immediate assis-tance/guidance of another doctor located at a far physicaldistance. In a similar vein, a casualty of military combatcould receive immediate communicative assistance in thefield by linking up with a doctor through a portable telecom-munications system. These two examples show that the useof telemedicine has the potential not only to save more livesbut also to improve health communication. It provides asound escape or supplemental alternative from the conven-tional health communication in doctor–patient interactionssuch as those that engage face-to-face, in-the-same-roomencounters that are typical in relationships between healthcare practitioners, health care organizations, and practi-tioners and patients (Turner, 1999, 2003).

Ability to Transcend Temporal Boundaries

Telemedicine has demonstrated its capability to improvehealth communication by alleviating constraints induced bytime (Bloom, 1996). In fact, not only does a telemedicinetask not need real-time interaction, such as in the case ofa remote expert consultation (Della Mea, 1999), but it alsodecreases patient anxiety caused by having to wait a longtime for a health care provider. Besides, still pictures overa phone line, amplified by direct oral communication, areuser friendly and have proven to be useful in the pre-healthcare arena. Compact audiovisual technology enables fast,immediate, and personal visual and audible interaction withthe patient. Now the doctor can perform auscultation andfundoscopic exams carefully and in real time.

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Ability to Reduce Costs

Telemedicine has been shown to be such an effectivemedical practice in several instances that its growthand application in the health care industry have risentremendously. What should be emphasized here is thattelemedicine in many cases can minimize the escalatingand draining costs of health services to all who benefitfrom it (Bloom, 1996; Crowe, 1998). We all know thatthe costs involved in health care and the resources neces-sary to transport patients to other states or even countriescan be enormous to some people. Therefore, expeditiousaccess to telemedicine can save both time and money. Bythe same token, it may be seen as an economical toolfor bringing international health care dollars to the UnitedStates (Perednia & Allen, 1995; Turner, 2003). One of thereasons for patient satisfaction with telemedicine, accordingto Gutske et al. (2000), is a reduction in waiting time, traveltime, and the time involved in arranging appointments. Theabsence of all of these issues can facilitate health commu-nication by eliminating many of the burdens involved instandard health care.

Ability to Increase Patient Comfort, Security, andSatisfaction

Another positive aspect of telemedicine addressed byresearchers and patients alike is that some patients appre-ciate the presence of several medical practitioners workingon them concurrently. In this sense, according to Callahan,Hilty, and Nesbitt (1996), many patients who underwenttelemedicine treatments felt more comfortable and assuredwith their cases while in the company of many collabo-rating doctors. Theoretically speaking, these higher levels ofcomfort and confidence among patients could be attributedto what media richness theory (Daft & Lengel, 1986)describes as an enriched social presence from severalattending physicians (Turner et al., 2003). This multidoctorpresence—that is, several attending medical personnelcollaborating and interfacing on one medical issue at hand—can relieve or diminish the uncertainty and fear by thepatient regarding his or her disease. These researchers alsofound that the collaboration of doctors in these telemedicinesettings in fact improves the reliability of the diagnoses.This, in effect, reduces the number or frequency of diag-nostic mistakes. In addition to this increased diagnostic reli-ability, the multiple parties involved have expressed that theexperience is a type of educational enrichment, as severalsources (i.e., doctors and other medical technicians) areexchanging information at one time (Whitten, 1995) and cancommunicate a rich pool of valid opinions on the medicalcase at hand. Beyond telemedicine’s general effective-ness, patients’ opinions of how telemedicine has positivelyaffected them are readily apparent from research studiesfocusing on patient satisfaction concerning telemedicine(Mair & Whitten, 2000). According to Gutske et al. (2000),

studies conducted by this team have revealed high levelsof satisfaction among patients subjected to telemedicineapplications. Another area of patient satisfaction emergesfrom the use of videoconferencing (Bashshur, Sanders, &Shannon, 1997).

Ability to Digitize Health Communication Via Web-Based Services

Because telemedicine embodies and engages a sort of virtualdomain, where the practice of health communication orservices occurs in a virtual world (Turner, 2003; Turneret al., 2004), conducting medical procedures and inter-faces within the limitations of time and space no longerpresents serious issues in the face of telemedicine tech-nologies (Turner & Peterson, 1998). In particular, with theadvent of Web-based medical and pharmaceutical compa-nies (e-health sites) that provide an enormous amount ofinformation on nearly every condition, drug, and treatment,individuals can turn to these services to conveniently andrapidly obtain information that could otherwise be obtainedby physically visiting and communicating with medicalpractitioners or pharmacists.

In the same train of thought, Web-based healthcare services (i.e., pharmaceutical companies, physicians’services, diagnostic information, etc.) offer substantialquantities and varieties of health information to Internetsurfers. Plus, e-mail can be used as a communicative conduitby which medical practitioners can provide direct corre-spondence and advice to patients who choose to stay at homeversus hauling themselves to clinics or hospitals for treat-ment purposes (Allen et al., 1996; Bloom, 1996). Studieshave shown that by taking these popular and inexpensivehealth communication services into account, recent demandand utilization of these services have increased significantly(Anderson, 1999). Even more amazingly, a study conductedby the Cyber Dialogue Health Practice (2002) anticipatedthat by the end of 2005, 88.5 million adults would be seekinghealth information and communication via e-health services.With this rapid and enormous elevation in Internet-basedhealth care communicative services, one would logicallyexpect that the demand for medical practitioners in clinicsor hospitals would noticeably decrease in the near future, ifin fact this has not already happened.

This section on the benefits of telemedicine adds to thescope of this article in that it further justifies the neces-sity and relevance of telemedicine in the health care systemand its growth beyond its current parameters. By the sametoken, this section helps us re-examine communication inthe health area by stressing that telemedicine does notmerely reorganize this context of health communicationbut also reshapes its very nature by offering many advan-tages (i.e., instant interaction between doctor and patient;better comfort, security, and satisfaction; lower costs; andbroader geographic allocation of resources). In fact, this

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section should be of great interest to health communica-tion scholars because telemedicine, as enhancing personalaccess to health information (i.e., WebMD.com), representsthe next evolutionary phase of global health care deliveryand exchange for both practitioners and patients. Truly,telemedicine offers a plethora of health communicationbenefits to an increasingly expanding global pool of medicalknowledge (Rusovick & Warner, 1998; Turner et al., 2004).Being aware of these benefits will allow health care commu-nity members to discuss clinical decisions in an interactiveway (and we all know that interactive communication ismore effective than one-way communication). We hope thatthis will make the health care system more user friendlyand allow for a truly integrated and more ideal system.

CHALLENGES TO THE DEVELOPMENT OFTELEMEDICINE

In spite of all of the promises and health communica-tion benefits that telemedicine is capable of delivering,it also creates serious questions that obstruct or threatenits growth and implementation in various ways. WhereasTurner (2003) enumerated a variety of challenges that jeop-ardize the advancement and success of telemedicine, wepropose four challenges that yield the greatest difficulty intelemedicine’s path and clarify these in more detail thanhave been provided in earlier research. These four mainchallenges are addressed in this section: (a) licensing andlegal issues, (b) challenges to patient privacy, (c) resistancefrom health insurance companies, and (d) limited knowl-edge and expertise in telemedicine. As such, we have iden-tified and described these four challenges in detail in thefollowing subsections (although other barricades exist thatimpede its progression and implementation).

Licensing and Legal Issues in Telemedicine

The first challenges—which are interrelated in manyrespects—that legally hinder the development oftelemedicine include issues related to interstate licensing,legal liabilities, and institutional credentialing of physicians(Stanberry, 1998; Turner, 2003). Unfortunately, many ofthese legal matters are still unanswered and unresolvedwithin both the U.S. health care and judicial systems. Forexample, in interstate medical transactions where mechan-ical devices are used for surgery or radiology, if there isa mechanical failure or glitch that results in harming thepatient, deciding on who is responsible for that accident isdebatable and can be a major headache for legal author-ities. Another key issue implicit in this scenario is thatthese practitioners who are treating and communicating withthe patient are operating out of different states. Becauselaws regarding telemedicine and health care certification areunique in each state, legal liability, malpractice, and juris-diction become serious matters of concern for the judicial,

legal, and medical systems (Blair, Bambas, & Stone, 1998;Turner, 2003). For instance, in the event that an inexperi-enced physician located in Arizona is physically operatingon a patient and is engaged in a live telemedicine commu-nication with a specialist in New York whose guidanceand direction botch the surgery and result in the patient’sdeath, the prosecutors and legal officials in Arizona wouldfind difficulty in placing blame and litigation on the partyin New York. An issue like this one is a typical scenarioin which telemedicine presents some legal and licensingissues. However, as telemedicine and its associated tech-nology evolve, feasible solutions (i.e., legal policies andamendments) to these problems should be discovered andmade available.

Challenges to Patient Privacy

Another serious impediment to the development oftelemedicine includes issues related to patient privacy.According to Gilbert (1995), because multiple individ-uals (i.e., technicians, nurses, etc.) are generally involvedin telemedicine communication, exposure of confidentialrecords to all parties concerned becomes a threat to theprivacy of that patient. Additionally, even though medicaldoctors accept the obligation of maintaining their patients’privacy rights, the other assisting parties involved in thetelemedicine communication may not be held to the samestandard (Turner, 2003). As a result of this risk to patients’privacy rights, telemedicine has struggled to gain accep-tance from the legal and medical communities (Sanders &Bashshur, 1995). However, again, as time progresses andthis issue is tackled by the medical and legal communitiesalike, solutions should be found to eliminate privacy risksto patients. Furthermore, these solutions should generateincreased acceptance of telemedicine practices by all partiesconcerned and, likewise, should alleviate the fear andfrequency of breaches to patient privacy laws.

Resistance From Health Insurance Companies

The next troublesome – and perhaps the most significant(Turner, 2003) – obstacle that telemedicine faces in gainingadoption is the difficulty of receiving reimbursement forservices from insurance companies that oppose unconven-tional consultations, such as the ones absent of face-to-face contact. For instance, according to Brecht and Barrett(1998), the U.S. Health Care Financing Administration,a national organization in charge of major health insur-ance companies, stipulates that reimbursement for medicalservices is usually available only when direct physicalcommunication (i.e., a face-to-face appointment) is held.However, this stipulation is not universal and required of allstates. There are some states that do not demand this imme-diate presence in medical consultations, such as California,Texas, and Oklahoma. Plus, these states even go as far as

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permitting such telemedicine services as appropriate substi-tutes for face-to-face appointments if recommended by theattending practitioner(s) (Turner, 1999, 2003).

Limited Knowledge and Expertise in Telemedicine

The last challenge to be addressed has to do with the limitedknowledge and expertise in telemedicine as well as theneed for enhanced and modified telemedicine systems. Inthis sense, little knowledge currently exists among medicalpractitioners on how to effectively and practically usevarious forms of telemedicine. This paucity of insight intotelemedicine, in effect, hinders the creativity to exploremore efficient and effective modalities of telemedicineapplications. As a result, teaching medical practitioners tolearn and adopt this new way of accomplishing healthservices, through telemedicine, has become a significanthurdle to implementation (Tanriverdi & Iacono, 1999;Turner, 2003; Whitten, 1995).

Special competence is also required before implemen-tation of telemedicine can be allowed and render successto those concerned. In this regard, a unique term, telecom-petence, was created to describe the required skills andcredentials practitioners must have in order to carry out thiskind of specialized work (Turner, 1999, 2003). Telecompe-tence is a must in order to be a health communication expertregarding telemedicine. In particular, according to Turner(1999), there is a three-stage process involved in such healthcommunication aptitude. As such, telecompetence consistsof (a) planning and establishing, (b) learning and use, and(c) formalizing routines. Unfortunately, achieving this levelof competence could be considered a major adversary totelemedicine implementation, because considerable trainingand finances are not always available resources to enablethis kind of campaign. To this end, in some medical settingswhere resources are limited, telemedicine may not be afeasible or affordable option.

In the following section, various forms of telemedicineare negatively criticized according to their subtractiveeffects on practitioner–patient communication. In each ofthe forms identified, individuals are left to communicatewith computers and other forms of technology, all of whichare absent or slight in physical human contact and exchange.As we argue, the social and communicative elements tothese telemedicine modalities dehumanize, dissocialize, anddepersonalize human behavior and contact. Additionally, weurge for a careful re-examination of whether telemedicinegenuinely serves humanity in a positive and fruitful way.As we clearly illustrate, this is not always the case.

SUBTRACTIVE COMMUNICATIVE EFFECTSOF TELEMEDICINE

In the present day and age, we know that a considerableportion of world society relies mostly on technology and

electronics for communications, memory storage, militaryoperations, and medical procedures. With the advent andadvancement of telemedicine—especially via the Internet—our medical and health care systems have taken a near-complete redirection in how health communication is chan-neled and exchanged. Humans on all sides of the healthcare system are now becoming digitized, virtual, and cyber(Rusovick, & Warner, 1998), also rendering subtractivecommunicative effects on this health care modality (Roback& Herzog, 2003; Short & Saindon, 1998). It is interestingthat the subtractive communicative effects of telemedicinehave often been overlooked in health communication. Inaddition, Turner (2003) argued that few studies have beenconducted on the communicative and interpersonal implica-tions of telemedicine. Thus, we believe that it is importantto address this issue.

Indeed, e-health services represent the most interper-sonally and communicatively reductive telemedicine tech-nologies that exist today (Effertz, Beffort, Preston, Pullara,& Alverson, 2004). The reason lies in the fact that face-to-face contact and nonverbal communication are absentor absolutely minimal in this medium (Leh, 2001). Assuch, telemedicine services on the Internet (i.e., e-mail)deprive humans of the fundamental contact that is so essen-tial in social interactions (Roback & Herzog, 2003; Short& Saindon, 1998). Although Walther (1996, 1997) hasargued that e-mail can provide a rich social presence, othersassert that e-mail services are mere exchanges of writtenwords, absent of any facial expressions and gestures (Leh,2001) and that they diminish interpersonal contact withothers because all communication is electronic (Aragon,2003). Also, because telemedicine can be a sort of dialoguebetween distant users, e-mail is oftentimes adopted as achannel to carry out such dialogue. Unfortunately, e-mail isappropriate only for asynchronous communication. In addi-tion, the present condition of the Internet does not usuallyproduce expeditious delivery times (Della Mea, 1999). Sothe question arises as to why e-mail is preferred if it isoftentimes slower than other forms of communication.

Likewise, health care information that is posted onWebMD.com does not require that the information-seekersconsult with a human being or physically visit with someonein an office. For instance, health care consumers can searchfor pharmaceutical information (i.e., prices, descriptions,side effects, and contraindications) and diagnostic informa-tion about diseases (i.e., images, symptoms, and current andinnovative treatments) on these types of sites without anypersonalized visits, phone calls, or any manner of commu-nication that requires two individuals to exchange ideas. Itseems that the Internet provides a user-friendly, omniscientencyclopedia of health care information, allowing doctorsto be thrown on the wayside or deemed obsolete in manycases. To this end, Internet-based telemedicine services can,in many cases, erase or at least significantly reduce the needfor human communication and contact.

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Yes, telemedicine applications do inflict a significantsubtractive effect on the social and communicative abilitiesbetween the doctor and the patient (Zuiderent, Winthereik,& Berg, 2003). According to Turner (2003), for somescholars in the field of communication, “the social presenceprovided by face-to-face interaction is more than a luxury,and provides a distinctive element to a communicationencounter” (p. 524). Cegela et al (1996) went even further,adding that this conduit of physically present communica-tion taking place in a face-to-face interaction (i.e., doctor–patient) serves as an important component in relational andinformational exchanges in the health communication envi-ronment. For this reason, it makes sense that telemedicinemay dissocialize and dehumanize the original and genuinepurpose of a doctor–patient interaction to the extent thattelemedicine may have a negative impact on the doctor–patient communication (Grigsby et al.; Turner, 2003, 2004).There are several cases showing that telemedicine can bedehumanizing and dissocializing. For instance, Akir (2005)found that telemedicine is so dehumanizing that lives caneven be endangered when remote medical diagnosis andsurgery cannot be performed because of a shortage of satel-lite links. Similarly, Bloom (1996) conducted a study onthe use of telemedicine among nurses. He found that nursesviewed telemedicine as dissocializing because they missedthe physical contact of touching patients.

In line with these contentions, in the case of patientswith chronic pain who primarily remain at home, physicalvisits and face-to-face communication between the doctorand the patient can largely be avoided through the useof telemedicine services and the brief or transient aid ofa nurse. For instance, patients who are physically immo-bile and require total care can still be helped through briefassistance of a nurse (Bashshur et al., 1997). Although thenurse must communicate with a physician regarding impor-tant decisions for the patient, the nurse becomes a medi-ator who primarily handles the doctor–patient communica-tion. As a result, the patient can rely mainly on that nurseto relay the doctor’s recommendations without any directcommunication with the doctor. In spite of the fact that thisreduction in doctor–patient contact may prove convenientin some respects, the patient and physician can lose sight ofeach other, and communication may just be “bounced off”another party.

Truly, do we want the future of telemedicine to lead us inthe direction of completely dissocializing and dehumanizingour communication between practitioners and patients? Canour society adapt to a world that shaves off the need forhuman beings to provide health care services? From whatwe have seen here, an important disadvantage of resortingto telemedicine is that it is subtracting, and close to elim-inating, our social human contact in health care settings(Zuiderent et al., 2003). This technology should not replacepatient–physician communication. Instead, it should onlybe an accessory to the health care practitioner. Given the

evidence shown by researchers (Effertz et al., 2004) thatthe social presence in Internet-based telemedicine technolo-gies is minimized considerably through these channels, thecontinued use and increase of telemedicine technologiescertainly lead us to believe that we are inevitably facedwith this dehumanizing outcome. It appears that we havetwo choices: (a) We can either learn to adapt and acceptthis new course the health care industry is taking, or (b)we can limit and control telemedicine to prevent it fromcontrolling us.

DISCUSSION

In this article we have attempted to provide healthcommunication scholars with a better understanding ofunique requirements, resources, issues, and opportunitiesfor telemedicine services. By moving toward this goal, wehave demonstrated that telemedicine has the capacity tolargely transform health care in both positive and nega-tive ways and to radically modify the personal face-to-face communication that has been the model of medicalcare since its inception. There are two opposite argumentsregarding whether telemedicine is beneficial to the healthcare community and for health communication in general.On one side of the argument, telemedicine services facili-tate health communication and offer a cornucopia of appli-cations that can improve medical operations in almost allsettings. On the other side of the argument, telemedicineservices present several challenges and subtract or disso-cialize precious human contact from the health care inter-action (i.e., Roback & Herzog, 2003).

In taking a pro-telemedicine stance, telemedicine is oneof the most beneficial tools that can considerably improvethe medical care system and circumvent obstacles in healthcommunication. We have entered an era where health careservices can be a mouse-click away and not the inevitabledrive down the street to the local clinic. There is no doubtthat telemedicine has made an important impact on people’slives. Its use of distant communication technologies facil-itates the delivery of tele-health care for the direct benefitof patients thanks to state-of-the-art equipment (e.g., videotransmission and e-mail services) that allows physicians,nurses, and other allied health professionals to providetheir services hundreds or even thousands of miles awayfrom their workplace. In fact, the literature has shown thattelemedicine, in its various forms and applications, offersmyriad health communication benefits (i.e., instant interac-tion between doctor and patient; better comfort, security,and satisfaction; lower costs; and broader geographic allo-cation of resources) to an increasingly growing body ofmedical knowledge.

In taking an anti-telemedicine stance, the challengesmentioned earlier demonstrate that telemedicine is far from

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perfect: legal and licensing issues, patient privacy, reim-bursement resistance from insurance companies, and educa-tional deficiencies in telemedicine (Turner, 2003). Althoughthe ability to better care for patients and save lives hasimproved, the scope and complexity of health care alsohave increased greatly. This is why telemedicine oppo-nents should open their eyes and strive to find solutions tothese challenges. A few grassroots approaches to rectifyingthese affairs are rallying the medical and legal communi-ties together in order to repair these issues and seek outany means necessary to demolish these obstructive elementsfrom interfering with telemedicine’s progressive course.We believe that lawyers can amend telemedicine laws toclarify and identify liability policies with regard to inter-state surgical operations (when the surgery takes place inone state while a physician is located in another state).

More important, another disadvantage of resorting totelemedicine is that it is subtracting and close to elimi-nating our social human contact in health care settings.This concern urges health communication scholars to eval-uate the specific communicative needs that have beenotherwise overlooked in the literature on telemedicine. Aswe have seen, the social and communicative elements tothese telemedicine modalities dehumanize, dissocialize, anddepersonalize human behavior and contact. For example,because telemedicine can take the form of a conversationbetween distant users, e-mail is oftentimes adopted as achannel to carry out such discourse. Unfortunately, e-mailis appropriate only for asynchronous communication. Thequestion arises as to whether medical technology will grad-ually replace patient–physician communication. We arguethat it should be only an accessory to health care prac-titioners. Establishing a basic understanding of what thismedical technology can lead to will help health communi-cation scholars enlighten the telemedicine debate by turningunique insights into more adequate approaches that willenrich and humanize mediated channels of health commu-nication, thereby offering remedies and clarifications foreffective health care exchange and delivery.

On the basis of our review of the current literature ontelemedicine, we believe that specific areas of inquiry thathave not yet been investigated require tapping. First of all,it might be interesting to further compare how Internet-and technology-based communication between patients andphysicians, in various specialties, differ greatly from face-to-face conversation. Grasping the effect on users andinformation exchange is a crucial factor in the adoptionof telemedicine by opposing forces. Available research toprovide reasonable explanations of the fundamental reasonsfor patient satisfaction or dissatisfaction with telemedicineand to analyze communication issues in any depth is stilllacking. The idea is that future research on the use oftelemedicine needs to be more scientifically rigorous to helppolicymakers reach informed decisions about the relevantuse of this medical practice.

In the same perspective, methods of achieving telecom-petence in medical personnel have proven to be a toughbattle to win. This failure to produce widespread telecom-petence suggests that researchers and think-tanks shouldgather and brainstorm on a feasible program to attainthis end. Because telecompetence is scarce, cost-effective,and systematic, training programs could be financed andcoordinated by hospital administrators and sponsors toallow for such important educational programs to occur.Another logical way to achieve general telecompetence inour health care practitioners could be targeting medicalschools to incorporate such training into their curricula.Because telemedicine is becoming increasingly popular inits use in the health care industry, health communica-tion professionals should devise methods of approachingmedical schools to encourage them to integrate coursesinto their programs that instruct the students on the mostcommonly used forms of telemedicine and the forms likelyto be used in the future. To this end, students would learnthe most important aspects of telemedicine services andwould, after receiving their certifications to practice, usethese services in their everyday jobs.

Third, we strongly encourage that scholars conductsurveys on the correlation between increased telemedicineusage and decreased patient visits to clinical buildings andactual medical practitioners. As usage of health communica-tion services on the Internet increases, the number of consul-tations and visitations with actual doctors and other medicalpractitioners should consequently decrease. In consideringthe current numbers (as shown on e-health Web sites) ofvisitors to, for instance, WebMD.com, we can expect asubstantial reformation in health clinics and the advance-ment of Internet-based sources for health care services. Bythe same token, it might be important to explore whetherdecreased complaints of sexual harassment, malpractice,and other issues occur as a result of increased usage ofe-health services. With this type of medium, nonverbalcommunication is eliminated, and misperceptions of prac-titioner conduct are minimized. This reduction is based onthe fact that only words themselves are used in interactionsor consultations. Unless overt sexual comments are made inan e-mail message, it is difficult to prove that plain contentsuggests sexual implications or innuendoes.

Finally, because of the rise of cyberterrorism, it is vitalfor health communication scholars to explore the potentialvulnerability of telemedicine services (particularly those onthe Internet) as targets for terrorism and criminal mischief.For example, pernicious hackers have been known to elec-tronically alter and mutilate Internet sites (Dunnigan, 2003),especially those that provide health communication infor-mation. Likewise, ex-patients who are angry with certaindoctors have been known to send harassing and intimidatingmessages to these health care providers in some situations.Additionally, there appears to be a deficiency in qualifiedsupport personnel to install the latest antivirus software

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and maintain existing hardware. Because of this lack ofsystem support, higher levels of virus and worm infec-tions of electronic patient data may result (Rigby, 2002).In sum, telemedicine services such as the ones listed earlierare susceptible to criminal and terrorist attacks. As such,protective measures should be developed and implementedto prevent such problems.

No matter what the forthcoming decades hold, and inspite of the challenges that telemedicine faces in its devel-opmental course, telemedicine shows considerable promisein shaping the future of medical care to a great extent. Infact, as Effertz et al. (2004) predicted, it may even becomemore popular and more widely used than traditional formsof health care services. As both health care providers andrecipients, we are in a propitious position to more fullyrealize the benefits that telemedicine provides. Our missionis to shape the future of health communication. As scholarsin this field, we can positively influence the destiny oftelemedicine by achieving a clearer understanding of thesocial and relational implications of these technologies and,in doing so, we can strive to enhance the experience for allparties (i.e., practitioners, patients, e-health users, etc.) andovercome the main challenges that threaten the growth andsuccess of telemedicine. Health communication scholarsultimately can take credit for winning this unceasing battleby shifting this controversial matter into one that does notinduce such heated debate across disciplines.

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